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I spent a good deal of this morning and yesterday reading over the proposed American healthcare bill (or at least, a compound version; there appear to be five doing the rounds). I don't want to blog on the details of it immediately. It's also a bill, which may well stall in the Senate or be overtaken by events, and which could yet be critically amended. It is the product of Congress, not the administration per se, and the lawyers have not yet got at it.

I had some instant worries about it though. In no particular order, I'll list them;

Firstly, it can't allow individuals to choose their doctor and treatment in the long run; instead, it will practically formalise the role of doctors as salaried employees of large medical groups.

Sarah Palin is onto something with the idea that this will then allow essentially ideological or non-medical outlooks on, say, euthanasia, abortion, transgender issues, or non-emergency treatments of chronic and congenital diseases to begin to influence medical decisions, rather than the present (unsatisfactory) arrangement of insurers and customers. It has in the NHS, after all.

Do you want the grown-up equivalent of suburban school monitors who do things right according to fashion rather than trained people who do the right thing making decisions? Have you ever seen a bunch of middle class people holding forth on what people need in fields they know nothing about? It's not pretty, and its deeply subject to social consensus.

Secondly, it seems to allow the government to reach into people's bank accounts, and to tax businesses, without calling what is happening a tax.

Thirdly, despite my initial feeling that the federal government could create a competitive option to set alongside insurance products, I'm not so sure now that any non-national insurance operation could compete. The logistical and monopsony power that the federal government develops will be expressed in terms of services offered; but very little will happen to lawyers, pharmaceutical companies, and existing insurance arrangements that will hold prices down.

Fourthly, I'm not sure Americans of any stripe will accept rationing by technocrat over rationing by money. Money, like land, is a form of expression in America, not a product of the State Treasury as in Europe. Even the liberals will just run to the lawyers--though this bill excludes judicial review in some critical areas.

Fifthly, why on earth are 'government public health training centres' part of this plan? Or fees on private health plans? Or 'home visitation rights'? or government regulation of residency programmes? Or government control of marriage and family policy? or something like ten new taxes, including an excise-style 'punishment' tax on the goods of nonparticipants? Why do military payments go up if the bill comes in?

Sixthly, this plan seems to extend to everyone in the United States, regardless of whether they are citizens or whether they have paid for it.

Seventhly, there are obvious tenth amendment issues, but the courts may also become involved in terms of taxes as punishment, the exclusion of various sorts of judicial review, the treatment of doctors in terms of pay, and the input of 'consumer representatives'. Also, if the government sets up some huge insurance operation, how unfair do restrictions imposed on non-participants or rivals have to be before they start violating the constitution? Or does the constitution only apply to States these days?

I think this bill is, like most bills, a vast set of political compromises. I think that the administration, and Rahm Emmanuel in particular, has decided that the moment when the big lobbies seem weakest, and when Americans are really worried about not being able to afford private care, is the moment to go for federal healthcare.

But, on an initial reading, I think that this bill will stall in the Senate, soak up political capital, and cost a huge amount. It may well deliver to the suburban middle classes on the credit borderline a degree of reassurance, but it might not do much for those of the working class with jobs (as opposed to those without citizenship or any inclination to look for jobs). It will accelerate the 'deprofessionalisation' of Doctors, and it will undermine the chance of States providing schemes in the future, for the offset benefit of relieving them of a burden now.

I have a feeling that this could seriously damage the Administration if Obama associates himself in the Senate with the Bill that has emerged from the House. All this as a fiscal crisis looms....you do have to admit that the man has guts, but I'm not sure they won't end up on a pole in 2010. It's also clear to me that very few on the left or the right want to engage in substantive debate over this, or to take on the lobbies.

I think there is a very strong chance this bill will fail, and if it doesn't that it won't work.

Here's a list of words and phrases I would have liked to have seen in the bill. Are they really beyond the realms of political possibility in America on the edge of its most serious crisis since the Depression?

UPDATE: Some of the answers to questions I asked above are becoming fairly obvious to me by the end of the day. For instance, a friend of mine who is a leading healthcare consultant in New England told me a while ago that many young doctors are embracing employee status, rather than being professionals in anything but title. I also get the point that some of my questions were technical; and, if the government is paying for medical education, I guess they would want some say in its standards. I wonder if the long term aim isn't to do away with a perceived distortion in which young doctors are funnelled towards lucrative electives and conscientious ones like the Surgeon General-designate have to treat people virtually on their own credit cards. Also, I'm not sure I'm too bothered about 'fairness' for insurance companies. Still, this is the biggest attempt to change the American social covenant, as it were, for forty years....I just wonder if it isn't going to end in tears as tempers get frayed and people start hyperventilating. I also take the point that the present system is not only unaffordable, but is actively bankrupting companies that got involved with it years ago.

I'm actually with Theodore Roosevelt on this one--government in itself is a kind of countervailing insurance for the 'little guy' against big banks and insurance companies and the like, or ought to be. Otherwise, the idea of employment rights and equal bargaining becomes a fiction.

I'll watch the spoof. If it's about a single level of fee for services rendered, allowing for skill and region variations, from lawyers, I will agree!

Watch the bond markets. I have a feeling the congressional bills won't be resolved into a workable proposal now before the fiscal situation gets bad in september/october; and that may mean that the air goes out of any reform effort. That would also seriously damage Obama, since, if he can't get a healthcare bill out of this congress, what on earth is he going to do on any other matter? The situation is not as bad as that surrounding Carter's 1978 energy bill, but it's approaching it....

Anyway, CC, all the best. I'm still a big 'NHS' man, though I think that we could learn from the German system too.

Hahaha. Just read the article; you are clearly some sort of communist for forwarding it.

Actually, the crisis of legal aid in this country is beginning to get serious. Many of the junior bar are on the edge of bankruptcy, and huge numbers of barristers can't get pupillage. Solicitors are being laid off by the tonne. When anyone can get work, the government takes ages to pay, and it pays little; many of the senior bar won't take the fees.

In response, the government is creating more and more tribunals, and have actually brought in serious proposals to means-test legal representation. I think it will all end in tears, but soon, if you are found guilty at trial, the government will try and use its powers to take your assets to pay for the defence they provided you with.

On the other hand, this country's use of tort, of pre-action pressures and costs as ways to discourage lawsuits, and of non-jury trials actually works, I think.

It's a terrible and heretical thought for a barrister, but I also find myself wondering if we shouldn't just merge the professions too....

I'd also point out, whilst I am on about it, that if you are jailed for a crime you didn't commit, then eventually cleared, Her Majesty will charge your compensation award 'bed and board' for the time that you were in prison.

I feel like posting about lawyers' fees, and what they do to American doctors....

"whilst I am on about it, that if you are jailed for a crime you didn't commit, then eventually cleared, Her Majesty will charge your compensation award 'bed and board' for the time that you were in prison."

I actually thought they already did that. I cannot think of anything more ridiculous than that.